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#56 Don't Feed Your Kids Brussels Sprouts [and say they're strawberries]

Charlotte Boshart | 08 October, 2019

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#56 Don't Feed Your Kids Brussels Sprouts [and say they're strawberries]

In my quest to understand why some in our field express disdain for working with the mouth—and keep an open mind while doing it—I came across this article. At first, I thought, good; this’ll give me definitive information—a study that compares two types of therapy and oral motor is one of them. Then I read it.

In my view, the research design and the mechanics are good, but the therapy content and their conclusions left me dazed and shaking my head. This is one of the supporting studies that negates doing oral motor therapy. I’ve truly enjoyed reading Dr. Forrest’s work through the years, but in truth, the anti-oral motor bias of this study was clear from the start.

I’ll summarize the study and include a few details, provide a few excerpts, and a critique. My personal comments are interspersed in italics.

The Study

Title:

“A Comparison of Oral Motor and Production Training for Children with Speech Sound Disorders”

Authors:

Karen Forrest, Ph.D., Indiana University, Bloomington

Jenya Iuzzini-Seigel, M.A., Marquette University (at that time)

Guest Editor, Gregory L. Lof, Ph.D.

Journal:

Forrest, K., and Iuzzini-Seigel, J. (2008). A Comparison of oral motor and production training for children with speech sound disorders.Seminars in Speech and Language, Vol. 29, No. 4,304-311.

Purpose:

To “compare the relative effect ofnonspeech oral motor exercises (NSOMEs) with traditionalproduction treatment (PT).” There were nine (started with ten) children withphonological/articulatory disorders (PAD).

It should be disclosed that as far as is known, the NSOME-kids DID NOT receive any sound-stimulation or opportunities to hear or imitate their target sound. Apparently, it would have invalidated the study.

Study Rationale and Literature Review:

In the one and a half pages preceding the “Methods,” Forrest and Iuzzini-Seigel present an overview on oral motor related topics.

The authors use Weismer’s definition of NSOMEs, “Any performance task, absent phonetic goals, in which structures of the speech mechanism—especially those of the upper airway” are used, (2006, page 319).Any performance task certainly leaves the selections wide open.
Much of the information in this section is a “replica” of the content in Dr. Forrest 2002 article, and Dr. Lof’s “[Five] Theoretical Reasons to Question Using NSOME.” They represent the standard questions/reasons (and answers) Dr. Lof poses in his convention handouts, articles, courses, and podcasts: Strength and tone, part-whole, task specificity and development, warm-up, and relevancy to speech.(I explain and respond to these questions/reasons in my Speech Link Podcasts and in the corresponding Handouts.)
This is not a “neutral” study; their anti-oral motor bias was obvious from the start.

Methods and Participants:

Originally, there were ten children, ages 3 years, 3 months, to 6 years, 3 months; recruited through newspaper ads and flyers. English was their primary language, they had normal oral structures, and passed hearing screening. Once the children were identified, all were assessed over the course of two, 1-hour sessions.

A volitional oral motor test (VOM) was given.(There were no specific details given about the VOM; more information about this would have been helpful.)
They administered: The Goldman-Fristoe (GFTA-2), the PPVT-3, did an oral-mech exam, a non-word repetition task, and language samples. Children who scored 85 or less on the GFTA-2 were considered to have PAD and considered for entry into the study. All PAD kids were given the CELF-P, and a 200-word sound probe of multiple productions of all consonants in all word positions.(The name and source of the sound probe was not disclosed.) Graduate students transcribed the sound probe from a video recording, then came to a consensus.
Criteria for enrollment in the treatment protocol: Each child had to have production errors on at least 3 unrelated sounds from the 200-word probe. Sounds were considered linguistically unrelated if they differed from one another by at least one of the features of place and manner.

Treatment Procedures: An alternating treatment design was used.

Criteria: Targets included at least one omitted sound, and a second sound that was either omitted or only produced in a single word position, or in a single lexical context. The control sound was an omitted phoneme that was linguistically unrelated to either treatment target.
NSOMEs were provided on one sound, PT was provided for another linguistically unrelated sound. A third sound was monitored as a control for nonexperimental effects. “For example, subject 1 (3 years, 8 months) received Production Treatment (PT) on /x/, and oral motor therapy on /c/, and /r/ served as the control.”
Each of the 9 subjects received both NSOMEs and PT during each 60-minute, 2 times per week sessions; which occurred first was randomly selected. Treatment: 20 - 30 minutes; 10-minute play-break in between.
PT sessions included 100 trials of three CVC stimuli in which the first C was the treatment target and the VC varied. Targets were presented with picture stimuli. Progress was monitored with the probes.
They share their selection of NSOMEs: “Sound-specific NSOMEs were selected from marketed sources (Chapman Bahr, 2001, and Pehde, et al., 1996). Although NSOMEs typically are used in conjunction with PT, such a design prevents evaluation of the independent benefit of each treatment type. For that reason, NSOMEs were trained independently of PT in this protocol.”

The NSOME Treatment Tasks (verbatim):

“NSOME treatment began withvarious resistance exercises and activities that required the child to move around the room (2 to 3 minutes) andfacial stimulation that included having the child pat and stroke his/her face (2 to 3 minutes).

Warm-up activities were followed by100 trials of three different NSOMEs, such as stroking the center of the tongue with a tongue depressor, applying resistance against the tongue, and lifting the tongue tip to the alveolar ridge.”Oral-sensory motor tasks can be fatiguing, but apparently not for these children.

Study Results:

The PT yielded a 30% increase, on average, in sound accuracy relative to pretreatment production compared with a 3% change that resulted from NSOMEs.
No changes in the control sound production were noted for any subjects.
No facilitative effect of NSOMEs was observed on production targets.(Not surprising.)
NSOMEs did not appear to provide children with increased oral motor skill.(How could they?)

The Authors’ Discussion: (verbatim)

“Results of this investigation do not support the use of NSOMEs as an effective procedure for improving speech sound production….There are many reasons to question the use of NSOMEs as a means of remediating speech disorders, including

theoretical (i.e. transfer of training)
anatomical (i.e. histology of speech articulators) [histology=the study of the microscopic structure of tissues], and
empirical concerns (i.e. data from the current study and others).”(The extremely weak data they are referring to is covered in the podcasts and handouts.)

The Critique

My concern with this study is not the mechanics—it’s THE TREATMENT METHODS and CONCLUSIONS.

It’s rather like feeding a child Brussels sprouts and saying they’re strawberries.

Although the title uses the term “oral motor,” nothing about the selected and administered nonspeech oral motor exercises, i.e., NSOMEs, is representative of the current oral sensory-motor therapy one would do with these types of speech-sound delayed, cognitively aware children.

And yet, it proved their objective—look, oral motor doesn’t work. It is my opinion that the study was set up to fail and prove a point. See? Kids don’t like strawberries.

There was an assumed misguided expectation that a random set of odd tasks would somehow magically transition into the correct production of the target sound that, by the way, was never presented to the child during therapy.

Regarding the selection of the “NSOMEs” used in this study, the authors state, “Sound-specific NSOMES were selected from marketed sources.” The two sources they reference are, 1) Diane Bahr’s book,Oral Motor Assessment and Treatment: Ages and Stages (2001), and a second book, 2)The Complete Oral-Motor Program for Articulation, byPehde, et al., 1996.

I’m familiar with Bahr’s book, and I do know it isnot written with the higher-level, more capable speech delayed child in mind, like those in the present study. In her 2008 ASHA Poster Session, she referenced her 2001 book:

“The book addresses assessment and treatment of children with feeding and motor speech disorders….The book discussed the interrelated nature of neurology, anatomy, physiology, and development with the treatment areas of feeding, motor speech, orofacial myofunctional, oral awareness/discrimination, and oral exercise/activities.It focused on the integration of these areas, so SLPs could view the topic or oral motor assessment and treatment as a whole.”

As for the second one (Pehde, et al., 1996), I have no knowledge or experience with this book. According to Amazon, it’s unavailable (i.e., out of print). Without being familiar with the book, my only response is that I’m disappointed in the task choices. Just speculating, perhaps the tasks represented the level of knowledge of the authors in 1996. Certainly, as I look back at my first book, I realize how much my knowledge has changed and progressed. Learning about and doing therapy is an evolutionary process.

With that said, following are my concerns about the tasks (from my current 2019 more-informed perspective!).

Regarding the NSOME tasks:

As far as I can tell, the tasks were treated as random, haphazard, unconventional sound-stimulation tasks. There was no stated therapy progression, no shaping of abilities or stimulation of speech sounds.
The authors say they were selected with specific speech sounds in mind. In the written account of the study, the tasks were not presented in this categorical manner.
There was no stated philosophy or rationale-base for using the NSOMES they chose.
Why were tongue resistance tasks included? Did the children need them? And how were the “resistance” tasks implemented? Was the child asked to participate or did the therapist just, as stated, “apply resistance against the tongue?”
Wasany oral sensory awareness included to aid in the therapeutic process of learning, as is typically included during real-life therapy? Did the therapist merely do the prescribed sequence of tasksto the child, or was the child actively involved in the process?

Question:

Is this what researchers believe oral motor is when working with speech sound delayed children? If so, they are mistaken and terribly misinformed. It is my view that if all oral motor therapy was implemented in this outrageous manner, our therapy-kids would make no progress, they would be totally unmotivated, and in therapy for the duration.

We SLPs are on the front lines and have the honored responsibility of guiding our therapy-kids. Although I am critical of the therapy in this study, I am grateful to the authors of this article for at least attempting to do a therapy comparison study. As far as I know, there’s only one other comparison study on "oral motor", and it’s a lesser-known article that only had two subjects.

But, it’s a start!

Thanks so much for all you do. Have a wonderful week!

Char Boshart

Resources and References:

Chapman Bahr, D. (2001). Oral motor assessment and treatment: Ages and Stages.Allyn & Bacon, A Pearson Education Company.

Forrest, K. (2002). Are oral-motor exercises useful in the treatment of phonological/articulatory disorders?Sem in Sp and Lang, Vol 23(1),15-25.

Forrest, K., and Iuzzini-Seigel, J. (2008). A Comparison of oral motor and production training for children with speech sound disorders.Seminars in Speech and Language, Vol. 29, No. 4,304-311. Online Access: Marquette University e-Publications@Marquette (in Milwaukee, WI); Speech Pathology and Audiology Faculty Research,https://pdfs.semanticscholar.org/c09d/fbc954137f61002293eeeebc8f19f6368d6b.pdf

Lof, G.L. (2006). Logic, theory and evidence against the use of non-speech oral motor exercises to change speech sound productions.2006 ASHA Convention Invited Presentation,11 pages.

Pehde, H, Geller, A, Lechner, B. (1996). The Complete Oral-Motor Program for Articulation. East Moline, IL: LinguiSystems. (Unable to access; out of print.)

Weismer, G. Philosophy of research in motor speech disorders. Clin Linguist Phon, 2006; 20(5): 315-349.